    <div class="container">
      <div class="bg-putih">

        <div class="jdl-page">
          <?php echo isset($judul)?$judul:'<font color="#ccc">Judul Belum Diberikan</font>'; ?>
          <div class="clearfix"></div>
        </div>

        <?php echo form_open('pasien_data/add', array('class' => 'form-horizontal', 'role' => 'form', 'id' => 'form')); ?>
        <div class="form-group">
          <label class="col-xs-2 control-label">Nama Pasien</label>
          <div class="col-xs-10">
            <input type="text" name="nama" class="form-control input-sm" placeholder="">
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Tanggal Lahir</label>
          <div class="col-xs-4">
            <input type="text" name="tanggal" id="tanggal" class="form-control input-sm">            
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Jenis Kelamin</label>
          <div class="col-xs-10">
             <input type="radio" name="jk" value="L" checked> Laki-laki
             <input type="radio" name="jk" value="P"> Perempuan  
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">No.Telp</label>
          <div class="col-xs-10">
            <input type="text" name="telp" class="form-control input-sm" placeholder="">
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-2 control-label">Alamat</label>
          <div class="col-xs-10">
            <textarea name="almt" id="almt" class="form-control input-sm" rows="3"></textarea>
          </div>
        </div>
        <div class="form-group">
          <div class="col-xs-offset-2 col-xs-10">
            <button type="submit" class="btn btn-primary btn-sm">Simpan</button>
            <button type="reset" class="btn btn-default btn-sm">Kosongkan</button>
          </div>
        </div>
        <?php echo form_close(); ?>

        <div class="clearfix"></div>
      </div>
    </div> <!-- /container -->

    <script>
     $("#form").validate({
      rules: {
        nama: {
          required: true,
          minlength: 3
        },
        ket: {
          required: true         
        }
      }
    });
    </script>

    <script type="text/javascript">
      $(document).ready(function(){
        $('#tanggal').datepicker({
          dateFormat: "dd/mm/yy",
          changeMonth: true,
          changeYear: true
        });
      });
    </script>